DEMYELINATING DISEASES

Nurse Licensure Examination Review

MULTIPLE SCLEROSIS

An auto-immune mediated progressive demyelinating disease of the CNS The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)

MULTIPLE SCLEROSIS
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CAUSE- unknown Multiple factors- viral infection, environmental factors,geographic location and genetic predisposition Common in WOMEN ages 20-40

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY  Sensitized T cells will enter the brain and promote antibody production that damages the myelin sheath  Plaques of sclerotic tissues appear on the demyelinated axons interrupting the neuronal transmission

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY  The most common areas affected are
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Optic nerves and chiasm Cerebrum Cerebellum Spinal cord

MULTIPLE SCLEROSIS
CLINICAL MANIFESTATIONS  1. visual problems such as diplopia, blurred vision and nystagmus  2. motor dysfunction  3. Fatigue  4. Mental changes like mood swings, depression  5. spasticity

MULTIPLE SCLEROSIS
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DIAGNOSTIC TESTS 1. MRI- primary diagnostic study 2. CSF Immunoglobulin G

MULTIPLE SCLEROSIS
NURSING INTERVENTIONS 1. Promote physical mobility  Exercise  Schedule activity and rest periods  Warm packs over the spastic area  Swimming and cycling are very useful

MULTIPLE SCLEROSIS
NURSING INTERVENTIONS 2. Prevent injuries  Wide stance walking  Use of walking aids  Wheelchair

MULTIPLE SCLEROSIS
3. Enhance bladder and bowel control  Set a voiding schedule  Intermittent bladder catheterization  Use of condom catheter  Adequate fluids, dietary fibers and bowel training program

MULTIPLE SCLEROSIS
4. Manage speech and swallowing difficulties  Careful feeding, proper positioning, suction machine availability  Speech therapist

MULTIPLE SCLEROSIS
5. Improve Sensory and Cognitive function  Vision- use eye patch for diplopia  Obtain large printed reading materials  Offer emotional support  Involve the family in the care

MULTIPLE SCLEROSIS
6. Strengthen coping mechanism  Alleviate the stress  Referral to the appropriate agencies

MULTIPLE SCLEROSIS
7. improve self-care abilities  Modify activities according to physical strength  Provide assistive devices

MULTIPLE SCLEROSIS
8. promote sexual functioning  Refer to sexual counselor

MULTIPLE SCLEROSIS
MEDICAL MANAGEMENT Pharmacotherapy
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Interferons Immunomodulators Corticosteroids BACLOFEN for muscle spasms NSAIDS for pain

Guillian-Barre’ Syndrome

An auto-immune attack of the peripheral nerve myelin Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves

Guillian-Barre’ Syndrome

CAUSE: post-infectious polyneuritis of unknown origin commonly follows viral infection

Guillian-Barre’ Syndrome

PATHOPHYSIOLOGY

Cell-mediated imune attack to the myelin sheath of the peripheral nerves Infectious agent may elicit antibody production that can also destroy the myelin sheath

Guillian-Barre’ Syndrome
CLINICAL MANIFESTATIONS  1. Ascending weakness and paralysis  2. diminished reflexes of the lower extremities  3. paresthesia  4. potential respiratory failure

Guillian-Barre’ Syndrome
NURSING INTERVENTIONS 2. Maintain respiratory function  Chest physiotherapy and incentive spirometry  Mechanical vetnilator

Guillian-Barre’ Syndrome
NURSING INTERVENTIONS  2. Enhance physical mobility
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Support paralyzed extremities Provide passive range of motion exercise Prevent DVT and pulmonary embolism Padding over bony prominences

Guillian-Barre’ Syndrome
NURSING INTERVENTIONS  3. Provide adequate nutrition
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IVF Parenteral nutrition Assess frequently return o gag refelx

Guillian-Barre’ Syndrome
NURSING INTERVENTIONS  4. Improve communication

Use other means of communication

Guillian-Barre’ Syndrome
NURSING INTERVENTIONS  5. Decrease fear and anxiety
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Provide Referrals Answer questions Provide diversional activities

6. Monitor and manage complications

DVT, Urinary retention, pulmonary embolism, respiratory failure

Guillian-Barre’ Syndrome
MEDICAL MANAGEMENT  ICU admission  Mechanical Ventilation  TPN and IVF  PLASMAPHERESIS  IV IMMUNOGLOBULIN

ALZHEIMER’S disease

A progressive neurologic disorder that affects the brain resulting in cognitive impairments

ALZHEIMER’S disease
CAUSES:  Unknown  Potential factors- Amyloid plaques in the brain, Oxidative stress, neurochemical deficiencies

ALZHEIMER’S disease
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CLINCAL MANIFESTATIONS 1. Forgetfulness 2. Recent memory loss 3. Difficulty learning 4. Deterioration in personal hygiene 5. Inability to concentrate

ALZHEIMER’S disease
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LATE CLINICAL MANIFESTATIONS 6. Difficulty in abstract thinking 7. Difficulty communicating 8. Severe deterioration in memory, language and motor function 9. repetitive action- perseveration 10. personality changes

ALZHEIMER’S disease
DIAGNOSTIC TEST  Neurologic examination  PET scan  EEG, CT and MRI  Other tests to rule out Vit B deficiencies and hypothyroidism  Autopsy is the most definitive

ALZHEIMER’S disease
Drug therapy  1. drugs to treat behavioral symptoms- antipsychotics  2. anxiolytics  3. Donepezil  4. Tacrine

ALZHEIMER’S disease
Nursing Interventions  1. Support patient’s abilities  2. Provide emotional support

ALZHEIMER’S disease
Nursing Interventions 3. Establish an effective communication system with the patient and family  Use short simple sentences, words and gestures  Maintain a calm and consistent approach  Attempt to analyze behavior for meaning

ALZHEIMER’S disease
4. protect the patient from injury  Provide a safe and structured environment  Requests a family member to accompany client if he wanders around  Keep bed in low position  Provide adequate lightning  Assign consistent caregivers

ALZHEIMER’S disease
5. Encourage exercise to maintain mobility

PARKINSON’s Disease

A slowly progressing neurologic movement disorder The degenerative idiopathic form is the most common form

PARKINSON’s Disease
CAUSATIVE FACTORS: unknown  Potential factors: genetics, atherosclerosis, free radical stress, viral infection, head trauma and environmental factors

PARKINSON’s Disease
Pathophysiology  Decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia  Clinical symptoms do not appear until 60% of the neurons have disappeared

PARKINSON’s Disease
CLINICAL MANIFESTATIONS  1. Tremor- resting, pill-rolling  2. Rigidity- cog-wheel, lead-pipe  3. Bradykinesia- abnormally slow movement  4. Dementia, depression, sleep disturbances and hallucinations  5. excessive sweating, paroxysmal flushing, orthostatic hypotension

PARKINSON’s Disease
Medical management  1. Anti-parkinsonian drugsLevodopa, Carbidopa  2. Anti-cholinergic therapy  3. Antiviral therapy- Amantadine  4. Dopamine Agonistsbromocriptine and Pergolide, Ropirinole anmd Pramipexole

PARKINSON’s Disease
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Medical management 5. MAOI 6. Anti-depressants 7. Antihistamine

PARKINSON’s Disease
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NURSING INTERVENTIONS 1. Improve mobility 2. Enhance Self- care activities 3. Improve bowel elimination 4. Improve nutrition 5. Enhance swallowing 6. Encourage the use of assistive devices

PARKINSON’s Disease
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NURSING INTERVENTIONS 7. improve communication 8. Support coping abilities

EPILEPSY
A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins

EPILEPSY

Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms

GENERALIZED SEIZURES

1. General Tonic-Clonic seizure(Grand mal) characterized by loss of consciousness and alternating movements of the extremities 2. Absence Seizure (Petit mal)common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares

GENERALIZED SEIZURES

3. Myoclonic seizure- characterized by brief, involuntary muscular jerks of body extremities 4. Akinetic seizure- general loss of postural tone and a temporary loss of consciousness- a drop attack

PARTIAL SEIZURES

1. Simple partial seizure- typically limited to one cerebral hemisphere 2. Complex partial seizure- begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements

Epilepsy
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DIAGNOSTIC TESTS 1. EEG 2. CT 3. MRI 4. LP 5. Angiography

Epilepsy
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Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery

Epilepsy
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Nursing Intervention 1. Care of patients during seizure 2. care of patients after seizures 3. patient teaching

BELL’S PALSY
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Causes 1. infection 2. hemorrhage 3. tumor 4. local traumatic injury

BELL’S PALSY
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MANIFESTATIONS 1. Unilateral facial weakness 2. Mouth drooping 3. Distorted taste perception 4. Smooth forehead 5. Inability to close eyelid on the affected side 6. Incomplete eye closure 7. excessive tearing when attempting to close the eyes 8. Inability to raise eyebrows, puff out the cheek

BELL’S palsy
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Diagnostic tests EMG Medical management 1. Prednisone 2. Artificial tears

BELL’S palsy
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Nursing Interventions 1. Apply moist heat to reduce pain 2. Massage the face to maintain muscle tone 3. Give frequent mouth care 4. protect the eye with an eye patch. Eyelid can be taped at night 5. instruct to chew on unaffected side

Trigeminal neuralgia
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Also called Tic Douloureux Painful disorder that affects one or more branches of the fifth cranial nerve CAUSES: repetitive pulsation of an artery as it exits the pons is the usual cause

Trigeminal neuralgia
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ASSESSMENT 1. Pain history 2. Searing or burning jabs of pain lasting from 1-15 minutes in an area innervated by the trigeminal nerve DIAGNOSTIC TESTS Skull x-ray or CT scan

Trigeminal neuralgia
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NURSING INTERVENTIONS 1. provide emotional support 2. encourage to express feelings 3. provide adequate nutrition in small frequent meals at room temperature

Myasthenia gravis

A sporadic, but progressive weakness and abnormal fatigability of striated muscles which are exacerbated by exercise and repetitive movements

Myasthenia gravis
ETIOLOGY  Autoimmune disease  Thymoma Women suffer at an earlier age and are more affected

Myasthenia gravis
Pathophysiology:  1. Acetylcholine receptor antibodies interfere with impulse transmission  2. Follows an unpredictable course of periodic exacerbations and remissions

Myasthenia gravis
CAUSE: autoimmune disorder that impairs transmission of nerve impulses ASSESSMENT FINDINGS  Gradually progressive skeletal muscle weakness and fatigue  Weakness that worsens during the day  Ptosis, diplopia and weak eye closure  Blank, mask-like facies  Difficulty chewing and swallowing  Respiratory difficulty

Myasthenia gravis
DIAGNOSTIC TESTS  1. EMG  2. TENSILON TEST  3. CT scan  4. Serum anti-AchReceptor antibodies

Myasthenia gravis
MEDICAL THERAPY  Anticholinesterase drugspyridostigmine and neostigmine  Corticosteroids  Immunosuppresants  Plasmapheresis  Thymectomy

Myasthenia gravis
NURSING INTERVENTIONS  1. Administer prescribed medication as scheduled  2. Prevent problems with chewing and swallowing  3. Promote respiratory function  4. Encourage adjustments in lifestyle to prevent fatigue  5.maximize functional abilities

Myasthenia gravis

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6. Prepare for complications like myasthenic crisis and cholinergic crisis 7. prevent problems associated with impaired vision resulting from ptosis of eyelids 8. provide client teaching 9. promote client and family coping

Meningitis

Infection or inflammation of the meninges covering the brain and spinal cord. Caused by bacterial, viral and fungal agents

Brain Abscess

A free or encapsulated collection of pus in the brain parenchyma Causes: usually secondary to another infection like- sinusitis, meningitis, dental abscess, mastoiditis, bacteremia and trauma

Encephalitis

Intense inflammation of the brain tisssue with lymphocytic infiltration, cerebral edema, degeneration of brain cells and diffuse nerve cell destruction

CNS infections
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ASSESSMENT FINDINGS Meningitis 1. fever, headache, vomiting 2. positive meningeal sings Brain abscess 1. headache, N/V, seizures, changes in LOC 2. Focal neurologic deficits

CNS infections
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DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. EEG MEDICAL TREAMENT 1. Antibiotics 2. Surgical drainage 3. Drugs to reduce increased ICP

CNS infections
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NURSING INTERVENTIONS 1. Frequent monitoring of neurologic status 2. Monitor intake and output 3. Administer antibiotics 4. Administer mild laxative to prevent constipation 5. maintain quiet environment

Neoplastic diseases

A brain tumor is a localized intracranial lesion that occupies space within the skull Primary brain tumors originate from cells and structures within the brain.

Neoplastic disease

The cause of brain tumors is unknown The only risk factor accepted is radiation exposure to ionization rays

Neoplastic disease
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CLINICAL MANIFESTATIONS 1. increased ICP
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Vomiting Headache. Especially early in the morning Vomiting Visual disturbances

Neoplastic disease
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2. Localized symptoms Hemiparesis Seizures Mental status changes

Neoplastic disease
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DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. PET 4. EEG

Neoplastic disease
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MEDICAL MANAGEMENT Surgery Chemotherapy Radiotherapy

Neoplastic disease
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NURSING INTERVENTIONS 1. promote self-care independence 2. improve nutrition 3. relieve anxiety 4. enhance family processes 5. provide pre-operative and postoperative care 6. manage pain

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